Paul M. Peloso

The epidemiology of head injuries in Sweden from 1987 to 2000

The purpose of the present study was to evaluate the variability in the annual head injury incidence rate in Sweden from 1987 to 2000. It was hypothesized that the annual incidence rate would decrease over time due to a variety of primary preventive strategies that have been introduced in Swedish society. We used the Hospital Discharge Register at the National Board for Health and Welfare and head injury codes 800-804, and 850-854 from ICD9 system and S2.0-S2.9, and S6.0-S6.9 codes from ICD-10 system. We evaluated the patterns of age, gender, external cause of injury (E-code), type of injury, length of hospital stay, and trends over time. Head injuries due to transportation collision were reduced over the 14-year period analysis. Falls persisted as the dominant cause of head injury. Overall, men had 2.1 times the incidence of head injury compared to women. There was a decline in younger ages experiencing a head injury over this interval, while the number of head injuries among elderly people increased over time. Concussion was about three times more frequent than fractures. Hematoma and diffuse or focal contusions had a much lower incidence rate than concussion. Concussions and fractures decreased over time. Diffuse or focal injuries showed a steady rate of occurrence over the study interval while hematoma increased. Although length of hospital stay varied widely from zero to more than 50 days, 73.6% of hospital days were confined to two days or less. The incidence rate is stable over this time frame. While head injuries attributable to transportation accidents decreased, falls made up an increasing proportion of head injuries. Since we observed an increase in head injuries among elderly, primary prevention strategies may need to be targeted at this age group, and at preventing falls.

Gulf War veterans with anxiety: Prevalence, comorbidity, and risk factors

Background: Veterans of the first Gulf War have higher rates of medical and psychiatric symptoms than nondeployed military personnel. Methods: To assess the prevalence of and risk factors for current anxiety disorders in Gulf War veterans, we administered a structured telephone interview to a population-based sample of 4886 military personnel from Iowa at enlistment. Participants were randomly drawn from Gulf War regular military, Gulf War National Guard/Reserve, non-Gulf War regular military, and non-Gulf War National Guard/Reserve. Medical and psychiatric conditions were assessed through standardized interviews and questionnaires in 3695 subjects (76% participation). Risk factors were assessed using multivariate logistic regression models. Results: Veterans of the first Gulf War reported a markedly higher prevalence of current anxiety disorders than nondeployed military personnel (5.9% vs. 2.8%; odds ratio = 2.1; 95% confidence interval = 1.3–3.1), and their anxiety disorders are associated with co-occurring psychiatric disorders. Posttraumatic stress disorder, panic disorder, and generalized anxiety disorder were each present at rates nearly twice expected. In our multivariate model, predeployment psychiatric treatment and predeployment diagnoses (posttraumatic stress disorder, depression, or anxiety) were independently associated with current anxiety disorder. Participation in Gulf War combat was independently associated with current posttraumatic stress disorder, panic disorder, and generalized anxiety disorder. Conclusions: Current anxiety disorders are relatively frequent in a military population and are more common among Gulf War veterans than nondeployed military personnel. Predeployment psychiatric difficulties are robustly associated with the development of anxiety. Healthcare providers and policymakers need to consider panic disorder and generalized anxiety disorder, in addition to posttraumatic stress disorder, to ensure their proper assessment, treatment, and prevention in veteran populations.

Critical evaluation of the existing guidelines on mild traumatic brain injury

The purpose of guidelines is to reduce practice variability, but they need to be evidence-based. We examine current mild traumatic brain injury guidelines, critique their basis in evidence and examine their variability in recommendations. A systematic search of the literature found 38,806 abstracts, with 41 guidelines. There were 18 sports-related guidelines, 13 related to admission policies, 12 related to imaging and 5 related to neuropsychological assessment. Some guidelines addressed several areas. Only 5 guidelines reported a methodology for the assembly of evidence used to develop the guideline. After appraising the guidelines against a validated index, we found that 3 of the 41 guidelines could be categorized as evidence-based. Two of these focused on paediatric patients and 1 on adult patients. Limited methodological quality in the current guidelines results in conflicting recommendations amongst them.

Predictors of incident chronic widespread pain among veterans following the first Gulf War.

ObjectiveWe sought to determine the predictors of incident chronic widespread pain (CWP), specifically, the effect of preexisting symptoms, stress, and psychosocial factors in the subsequent development of CWP among veterans from the first Gulf War (GW). MethodsWe conducted a structured telephone survey (baseline) of military personnel originally from Iowa who were either eligible for or deployed to Operation Desert Shield/Desert Storm, approximately 5 years postconflict. We conducted a follow-up, clinical, in-person study of those who met a priori-defined outcomes of symptoms of cognitive dysfunction, depression, or CWP, and also a sample of those who did not meet any of the outcomes of interest. ResultsA total of 370 of 602 evaluated GW veterans were free of CWP 5 years postconflict. At follow-up, 69 (19%) of these had developed CWP. A positive family history of medically unexplained persistent symptoms [odds ratio (OR)=4.8 (2.3, 13.2)] was strongly associated with CWP. At baseline, individuals who reported preexisting symptoms of bronchitis [OR=4.9 (1.9, 12.3)] and cognitive dysfunction [OR=2.1 (1.1, 4.2)] were more likely to develop CWP. Alcohol use [OR=0.2 (0.1, 0.7)] was protective against CWP. Rather than combat-related exposure per se, the perception of stress at the time of the GW [OR=1.6 (1.1, 2.3)] correlated with CWP. DiscussionAmong the GW veterans evaluated longitudinally in this study, family history, predeployment symptoms, and the level of perceived stress during the GW were associated with subsequent development of CWP.

Fibromyalgia and Exercise Training: A Systematic Review of Randomized Clinical Trials

Abstract Objective. This review evaluates the effects of exercise training for individuals with fibromyalgia syndrome (FMS). Methods. Seven bibliographic indices (1966–2000) were searched for experimental studies containing physical exercise training for FMS. The methodological quality and adequacy of training stimulus were rated. Studies meeting ≥50% of the quality criteria and applying adequate exercise training stimulus were classified as High Quality Training Studies (HQTS). Results. Fourteen experimental trials were found; six were HQTS of aerobic exercise. In the HQTSs, improvements reported were: tender points =4 of 4 of the HQTS using this outcome measure; cardiorespiratory fitness =3 of 4; global well-being =3 of 5; and fatigue and sleep =2 of 5. There is moderate benefit in FMS from supervised aerobic exercise training. Details about dosage for muscle strengthening or flexibility training were insufficient to evaluate the adequacy of the training stimulus. Further research is needed to describe the long term effects of all types of exercise training and to examine strengthening and flexibility training in FMS.

Expanding the armamentarium for the spondyloarthropathies

Ankylosing spondylitis (AS) is a member of the family of spondyloarthropathies, which are inflammatory arthritides largely involving the axial skeleton and commonly accompanied by peripheral arthritis. Genetic factors, particularly the presence of HLA-B27, are major contributors to the susceptibility for AS. Despite some therapeutic advances, the treatment options for patients with AS and related disorders have been limited. Several lines of evidence have led to the hypothesis that patients with AS might benefit from treatment with tumor necrosis factor (TNF). Specifically, TNF concentrations are known to be significantly elevated in the synovium of patients with rheumatoid arthritis (RA), in the inflamed gut of patients with inflammatory bowel disease, and in the inflamed sacroiliac joints of patients with AS. The anti-TNF agents have been shown to be of benefit in, and currently have indications for, RA (etanercept, infliximab, adalimumab), Crohns disease (infliximab), and psoriatic arthritis (etanercept). Because the spondyloarthropathies share pathogenetic mechanisms with the above-specified disease states, studies have been conducted to evaluate the effectiveness of anti-TNF agents in several disorders, including AS. Data from clinical trials so far with infliximab and etanercept show that patients with AS and related disorders achieve significant improvement in clinical signs and symptoms based on validated outcomes measures. Computed tomography and magnetic resonance imaging (MRI) can facilitate the early diagnosis of AS. Studies with infliximab using MRI together with updated scoring methods demonstrated significant decreases in associated spinal inflammation. TNF antagonist therapy is well tolerated in patients with AS, with a side effect profile consistent with the prior experience of patients with RA.

Further studies are needed to assess the competing therapies for neck pain.

While reading the review by Ernst 16 in this issue of the Journal of Pain, we asked ourselves, “Has this review helped us advance the science around the treatment of neck pain, or not?” The answer is mixed. Although there is a clear need for more randomized trials in neck pain in general, including manipulative techniques, there are methodologic issues in this review and unsupported statements of opinion that give us pause. We would first like to address some the methodologic issues and provide alternate points of view and then address the issue of chiropractic spinal manipulation in the broader context of neck pain management.